Options for Reimbursement

Principal Illness Navigation (PIN) & PIN-Peer Support

• Codes: G0023, G0024, G0140, G0146
• Use: Monthly care-management for patients with serious, high-risk conditions (like cancer).
• Navigation Fit: Directly recognizes the navigator role in barrier mitigation, coordination, education, and linking to community resources.
• Value-Based Angle: Supports care transitions, reduces avoidable ED use, improves adherence.

Community Health Integration (CHI)

• Codes: G0019, G0022
• Use: Monthly services by community health workers (CHWs) under supervision.
• Navigation Fit: Addresses SDOH barriers—transportation, housing, food insecurity—through community linkages.
• Value-Based Angle: Improves equity and patient access, helping organizations meet quality metrics tied to social risk.

Social Determinants of Health Risk Assessment (SDOH RA)

• Code: G0136
• Use: 5–15 minutes to administer a standardized SDOH screening tool.
• Navigation Fit: Often performed by navigators at intake; results feed into care planning & referrals.
• Value-Based Angle: Aligns with CMS Interoperability/Health Equity measures; documents unmet needs that impact value-based contracts.

Chronic Care Management (CCM) / Complex CCM

• Codes: 99490, 99439, 99491, 99487, 99489
• Use: Monthly management for patients with ≥2 chronic conditions.
• Navigation Fit: Navigators often track adherence, coordinate specialty visits, and monitor symptoms.
• Value-Based Angle: Helps meet quality measures (A1c control, blood pressure control, etc.) and reduces hospitalizations.

Principal Care Management (PCM)

• Codes: 99424, 99425, 99426, 99427
• Use: For patients with one serious chronic condition expected to last ≥3 months.
• Navigation Fit: Navigators handle education, reminders, and care coordination for the single diagnosis (e.g., breast cancer).
• Value-Based Angle: Demonstrates proactive management of high-risk patients—a hallmark of value-based care.

Transitional Care Management (TCM)

• Codes: 99495, 99496
• Use: 30-day period post-discharge, with required contact within 2 business days.
• Navigation Fit: Navigators often complete the initial outreach, medication reconciliation support, and appointment scheduling.
• Value-Based Angle: Reduces readmissions—a key cost and quality metric in value-based contracts.

Advance Care Planning (ACP)

• Codes: 99497, 99498
• Use: Face-to-face discussion of goals of care, advance directives, treatment preferences.
• Navigation Fit: Navigators can prepare patients/families and provide education, though billing is by a physician/QHP.
• Value-Based Angle: Ensures patient goals are honored; tied to oncology quality programs (QOPI, CoC, OCM legacy).

How to Position Navigation in VBC

• Document time & activities clearly: barrier addressed, referrals made, care plan updates.
• Align services with quality metrics: screenings, SDOH documentation, transitions of care.
• Pair with risk-based contracts: Codes offset costs while showing measurable navigator impact.
• Integrate into team workflows: Navigators supply the “care coordination backbone” that makes CCM/PCM/TCM feasible.